RESENTED BY CHARLES BLAIR D. S

85 Catawba Street

P. O. Box 986 Belmont, North Carolina 28012-0986

866.858.7596 ∗ 704.822.3142 (F) www.practicebooster.com ∗ [email protected]

STAY OUT OF JAIL: THE TOP CODING ERRORS

PRESENTED BY: CHARLES BLAIR, D. D. S.

DECEMBER 9, 2011

1© 2011 All rights reserved -

STAY OUT OF JAIL: THE TOP CODING ERRORS

PRESENTED BY: CHARLES BLAIR, D. D. S.

1. Coding as presented has been researched. Statements made do not

DISCLAIMER

1. Coding as presented has been researched. Statements made do not necessarily apply to all plans as there is great variation. There is no guarantee that a given plan will reimburse along the guidelines presented.

2. Always code “what you do.”3. Follow the current CDT code set exactly to the best of your ability.

CDT-2011/2012 (CURRENT CODE)

Code and report “what you do” strictly by the current CDT-

2011/2012.

HIPAA is “law of the land”

© Dr. Charles Blair & Associates, Inc.

Codes are not specialty-specific

New codes every two years

There are almost 500 codes

“Any person who, with intent to defraud or knowing that he

or she is facilitating a fraud against an insurer, submits an

ANTI-FRAUD LAW LANGUAGE(TYPICAL STATE LAW)

or she is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or deceptive

statement, is guilty of insurance fraud.” (Ohio Law)

“I hereby certify that the procedures as indicated by date are

ADA CLAIMS FORM LANGUAGE

in progress (for procedure that require multiple visits) or have

been completed”

TREATMENT PLAN $1,000

DISCOUNTED FEE FOR PRE-PAYMENT


5% CASH DISCOUNT $ 950

What goes on the form? $1,000 or $950?


DISCLOSING CO-PAY FORGIVENESS

All states prohibit co-pay forgiveness without third-party

notification.

Virtually all PPO’s prohibit co-pay forgiveness!


If you “forgive” the co-pay in an isolated situation, the remarks

section should read:

“The patient is not participating in the cost of treatment.”

Note: Always disclose fee forgiveness to third-party.

AUDITS

AUDIT ELEMENTS

The audit would confirm:

That the procedure was performed.

That the procedure was “medically necessary.”


That the procedure was not cosmetic.

That the fee charged was the same fee charged to non-insurance

patients in similar circumstances.

That the clinical protocol for non-insurance patients was the same

clinical protocol for insurance patients in similar circumstances.

AUDIT ELEMENTS (CONTINUED)

That the procedure is not up-coded

Example: A surgical extraction (D7210) is charged instead of a

routine extraction (D7140).

Th t th l i f t


That the claim form was accurate.

That the procedure was properly represented by the current CDT-

2011/2012 code reported.

FEES

CAN YOU LEGALLY. . .

Charge different fees for different people?

Charge different fees for different plans?

Charge different fees for same procedure code?


Charge different fees for non-insurance patient versus PPO

Insurance patients?


FULL FEE ON CLAIM FORM - ALWAYS

SUBMIT FULL UNRESTRICTED FEE. WHY?

For calculation of coordination of benefits for proper patient

reimbursement.


So you don’t miss a PPO increase in fee reimbursement.

For purposes of UCR setting by insurance companies with

claims filed, not fees registered.

Determine write-offs for each plan to compare.

MANAGED CARE ASSESSMENT

Fees

Quality of Patient

Administrative Hassle


Managed Care Penetration

Percentage of Current Practice

Percentage of New Patients

CODING ERRORS: PREDICTIVE ERROR CORRECTION


CLEANING UP YOUR CODINGLOWER ERRORS!

Delete/inactivate the deleted codes under CDT-2011/2012.

Enter only the new codes under CDT-2011/2012 that specifically

apply to your practice. For the typical GP practice, only five to


ten of the new codes may apply.

Delete inactive codes.

Print a report showing fees and counts for each CDT procedure to

determine miscoding.

CLEANING UP YOUR CODINGLOWER ERRORS!

Make sure that the numerical code sequence for range starting

D0120 and ending D9999 is used only for valid CDT codes.

Move in-office codes such as broken appointment, deliver crown,

etc to code numbers below code D0120 For instance code these


etc. to code numbers below code D0120. For instance, code these

in-office codes using range numbers D0000 – D0119.

ORAL EVALUATIONS (EXAMS)


COMPREHENSIVE ORAL EVALUATIONS

D0145-Under age 3 includes counseling.

D0150-Age 3 and up – probing and charting “where indicated”


D0180-Must be perio patients (or have perio risk factors) and full-mouth probing and charting is mandatory.

COMMON EVALUATION (EXAM) LIMITATIONS

“2 /Year Rule” or “1/Six Months” (OF ANY KIND)

D0140 Problem-Focused Exam Issues

“Not paid with definitive procedure” Rule


Not paid with definitive procedure Rule

Always a “Stand Alone” Code

Subject to 2/year rule

Can be used infrequently at recall with extra time.

EVALUATION-TYPE CODES

Periodic (Recall) D0120

Limited/Problem-Focused Emergency D0140

Under Age 3 Evaluation D0145


g

Comprehensive (N.P./Established) D0150

Comprehensive Perio Evaluation N. P. with Perio) Established Patient

D0180

Detailed & Extensive (Follows D0150/D0180) D0160

Re-Evaluation (Limited) (Follows D0140/D0150/D0180) D0170

CONSULTATION (D9310)*

Referral from dentist/physician.

For dentist opinion - may or may not do work.

Generally use (D0140) or (D0150) for second opinion, as


applicable, at patient’s request.

* May or may not be reimbursed

CASE PRESENTATION (D9450) - DETAILED VISIT

Used as a “visit” code to present treatment plan at a later date (after

evaluation).


Is not generally billed/reimbursed.

Office Visit Observation (D9430)

Not generally used for billing code.

PALLIATIVE (D9110)

One of the least-reported codes. Palliative is a minor procedure (not a definitive procedure) at an emergency visit with pain/discomfort reported by the patient.

Typically allowed up to 2 to 3 times a year.

N t “t k b k” d d ll t bj t t d d tibl


Not a “take-back” code, and generally not subject to a deductible.

Cannot report any other treatment on same visit date with most plans. X-

rays are OK.

Always use narrative

Variable fee, depending on procedure and the time spent.


MINOR PROCEDURES(PALLIATIVE – D9110) AT EMERGENCY VISIT

Smooth sharp corner of tooth

Adjust occlusion for pain relief

Remove decay, IRM placed


Desensitize tooth

Open tooth (partial debridement) or lance abscess for pain relief

Partial heavy calculus debridement (only with patient complaint of discomfort)

Apthous ulcer relief

PULP VITALITY TEST (D0460)

May “count” as evaluation (D0140) and the UCR fee is lower.

May not be reimbursed in addition to problem-focused evaluation

(D0140) on same service date.


Generally don’t use this code unless “stand alone.”

However, the pulp vitality test is considered a “stand alone” code.

EMERGENCY FEE VARIANCE

Desensitize Application

At Checkup (D9910) – Free/$15

Emergency Visit (D9110) - $65


Coronal Remnant Extraction (D7111)

At Checkup – Free?

Emergency Visit - $65

X-RAY PROTOCOLS

Develop x-ray protocols:

Doctor orders and reads x-rays!

New Patient X-Rays (Full Series or Pan/4BWX)


Recall X-Rays (2BWX or 4 BWX)

Growth & Development (Age 6-10) – Start Pan

COMMON X-RAY LIMITATIONS

Full Series or Pan – Every 3 or 5 years

Maximum x-ray reimbursement – full series UCR

Bitewings – once per year/twice for children?


Maximum bitewing reimbursement – four bitewings limitation at

recall visit

Vertical bitewings – 7-8 films (D0277) may pay 80% of full series

fee but may count under full series limitation rules. May

downgrade to 4BWX in some cases.

INTRAORAL PERIAPICALS (D0220/D0230)

Generally one or two periapicals are reimbursed at problem-focused

(emergency) exam (D0140) or Palliative (D9110) appointment.

Use (D0230) for each additional periapical.


Periapicals taken at the emergency visit do not generally affect the

“once-a-year” bitewing rule.

Multiple bitewings taken at an emergency visit will often affect the

“once a year” bitewing rule. One bitewing may, or may not,

“trigger” rule.


PANORAMIC FILM (D0330)

Payable every 3 or 5 years, just like full series (D0210). Either one or other.

If a pan and bitewings (D0272/D0274) are taken on the same service date,

then many carriers convert to the lower full series UCR payment amount.

i i id l b b i lf i i d


Sometimes Pan is paid only; a pan pays best by itself on a given service date.

Consider pan or 4BWX at an emergency visit to “get it out of the way”.

CONE BEAM CT (I-CAT)

D0360 Scan/Data Capture


D0362 2D Reconstruction

D0363 3D Reconstruction

ORAL IMAGES

ORAL/FACIAL IMAGES(D0350)

Generally not payable

DIAGNOSTIC CASTS(D0470)

Generally not payable

Orthodontic records benefit

Add value with photos

Orthodontic records benefit

PROPHYLAXIS

Definition

Prophylaxis is preventative

Scaling and polishing of tooth structures


Scaling and polishing of tooth structures

Gingivitis is inflammation of Gingiva

Includes removal of irritational factors (gingivitis)

No mention of Perio-free status in descriptor

CHILD PROPHYLAXIS

Child prophy (D1120)primary or transitional dentition

2 Bitewings (D0272) generally until second


2 Bitewings (D0272) generally until second molars are erupted.

* Bitewings not generally age-dependent


ADULT PROPHYLAXIS*

Adult Prophy (D1110)

Transitional or permanent dentition

3 Bitewings (D0273)


3 Bitewings (D0273)

4 Bitewings (D0274)

*14 years of age and up is the most common limitation, sometimes 16 years. Occasionally D1110 is paid for 12-13 year olds.

*Also second molars erupted can be criteria.*ADA code does not specify age, but insurance generally does.

ADULT PROPHY (D1110)

Extended Prophy

Adult Prophy (routine)


Teenage Prophy

Brief Prophy (partial)

D8999 Utilization

FLUORIDEFLUORIDE

FLUORIDE APPLICATION LIMITATIONS

Payable once or twice per year. Fluoride cannot be in prophy paste.

Fluoride D1203/D1204 are long-time codes and for low-risk


carries patients. Any fluoride okay. Includes fluoride varnish.

Match fluoride (D1203/D1204) with prophy status (child/adult).

*Generally payable twice a year but trend is once per year. Often payable up to 16-18 years of age.

FLUORIDE VARNISH (D1206)

Same code for adults or children

Only can use fluoride varnish

Moderate to high caries risk patients only:


Moderate to high caries risk patients only:History of caries wears braces, susceptible to root caries, and extensive crown and bridge.

D1206 maybe a higher fee

OPERATIVE RESTORATIONS


RESTORATIVE DEFINITIONS

Don’t charge for liners, bases and etching.

Operative restorations are in occlusion and have adjacent contact, if

li bl


applicable.

Posterior Amalgam/Composite Restoration*: Always in Dentin!

*Includes all bases, liners, and etching.

NEW CODE (EFFECTIVE 1/1/11)

Preventative Resin Restoration (PRR) D1352

Preparation in enamel by DDS.

Includes any sealant in radiating grooves


Includes any sealant in radiating grooves.

Sealants (D1351): Pits and fissures are in enamel.

“OPERATIVE FRAUD ?”

Closing Diastema or “Bonding” (Cosmetic)

3-surface anterior

4-surface anterior/incisal angle


Perio Splinting

Reporting of routine fillings instead of Perio splinting.

DEFINITIONINCISAL “EDGE” OR INCISAL “ANGLE”?

1 Surface D2330 4 Surface D2335 (MIFL/DIFL)

INCISAL EDGE INCISAL ANGLE


2 Surface D2331

3 Surface D2332

INLAYS/ONLAYS

INLAYS/ONLAYS

Inlays are generally reimbursed as amalgams/composites.

Onlays can be reimbursed with excellent documentation (photos, x-

rays, need for crown, etc.).


To be considered an onlay the cusp(s) must be “capped” or “shoed.”

An onlay always involves the facial and/or lingual surfaces.

MOD is, not an onlay.

MOF, MOL, MODFL-all okay.


ONLAY/CROWN (SIX) CRITERIA

1. Missing Cusps

2. Undermined Cusps


3. Fractured Cusps

4. Fracture

5. Decay

6. Endodontic Tooth

INLAY/ONLAY MATERIALS

Three types of inlay/onlay materials:

Gold

Ceramic/Porcelain


Resin-based (lab - Cristobel®, Artglass®, Bellglass®)

Resin-based (lab) materials:

Sometimes excluded as a material

May reimburse 40-50% less than gold/ceramic material

CROWN AND BRIDGEWORK

Use correct metal

Price accordingly


Match correctly the pontic material to the retainer type of material

CROWN BUILDUP TYPES

Single Crown Codes:

Core Buildup (D2950) - typically for vital - sometimes Endo

Indirect Cast or Milled Post (D2952) – Endo teeth


Prefab Post & Core (D2954) – Endo teeth

Bridge Buildup Codes:

D6970, D6972 and D6973

CORE BUILDUP (D2950/D6973)

Must be for “retention” of crown and “strength” of tooth.

Cannot report for “box form”, “undercuts”, or “ideal prep.”

“A core buildup is required for the retention of the crown and


strength of the tooth.”

“65% of the tooth was missing.”

“The tooth was endodontically treated on mm/dd/yy”. Enclosed is

completed endo x-ray.

PREFAB POST/CAST BUILDUPS

For Endodontically treated teeth (only).

Routinely approved.


Watch Cast or Milled Buildup miscoding!


EXTRA LAB PROCEDURES W/ PARTIAL

Bill code (D2971) plus crown procedure.

Lab charges extra $50 - $70.


About $150 fee for the procedure.

ENDODONTIST

PRIMARY TOOTH ENDO PROCEDURES

Use these codes for primary teeth:

Pulpotomy (D3220) – Vital Tooth

Pulpal Therapy Anterior (D3230) Necrotic*


Pulpal Therapy – Anterior (D3230) Necrotic

Pulpal Therapy – Posterior (D3240) Necrotic*

*Higher Fee Paid

PULPAL DEBRIDEMENT (D3221)

“Open tooth” and “get out of pain” code for referral to Endodontist.

Can be a “take-back” code if RCT treatment follows later in the same billing office


same billing office.

Some carriers re-map (D3221) to the Palliative (D9110) code for payment.

Palliative (D9110) is an alternative at the emergency visit.

PERIODONTICS

CROWN LENGTHENING (D4249)

Hard tissue (remove bone) procedure.

Lay flap mesial and distal to tooth.


Bone is not diseased (no Perio issues).

No Endo Apex problems

Six week wait or more for crown prep/impression.


PERIO SPLINTING* (MOBILE TEETH)

(D4320) Provisional Splinting - Intracoronal

(D4321) Provisional Splinting - Extracoronal


*Do Not report individual Composite Restorations - fraudulent!

QUAD SCALING & ROOT PLANING (SRP)*

4-5 mm pocket depth , BOP, evidence of bone loss

(D4341) 4 teeth or more (quadrant)


(D4342) 1-3 teeth (list teeth on form)

*D4910 follows Scaling and Root Planing or osseous surgery procedure.

PERIO ONGOING MAINTENANCE (D4910)*

Show history of SRP/surgery, plus attach full mouth charting with initial D4910 form. Turn switch “on”.Always Follow SRP or Perio Osseous surgery.Don’t alternate D4910 with prophy (D1110).(D4910) treatment is “indefinite” and “ongoing”


(D4910) treatment is indefinite and ongoing .Many carriers require two quads of SRP to qualify for D4910 visits. Does not include Periodic Evaluation (D0120) or Comprehensive Perio Evaluation (D0180). D0180 requires full mouth chart and probing to report.

*Sometimes D0180 evaluation is reported, but generally reimbursed as D0120.

“If periodontal maintenance D4910 is not reimbursable,

D4910 NARRATIVE

please pay the alternative benefit of Prophylaxis, D1110.

“Periodontal maintenance, D4910 is inclusive of Prophylaxis,

D1110.”

CAN D4910’S BE FOLLOWED BY PROPHYS?CAN D4910 S BE FOLLOWED BY PROPHYS?

GROSS DEBRIDEMENT TO ENABLE ORAL EVALUATION AND DIAGNOSIS (D4355)

“A Gross Debridement was necessary for a subsequent evaluation.”

“Patient has not seen dentist in three - five years.”

Do not charge out Comprehensive Evaluation on same service date! Charge at

2nd visit.


With limited debridement, consider using Palliative (D9110) if the patient reports

they have discomfort at an emergency visit.


CONTROLLED RELEASE VEHICLE (D4381); PER TOOTH

Includes Arestin®, PerioChip®, Atridox®

Generally not payable at initial SRP appointment.

b bl i k l i ( 4910) i i i b


May be payable at six week re-evaluation or (D4910) visit - getting better.

Documentation: 5-6-7mm depth pocket; BOP; probing and charting

D4381 is coded per tooth. Fee varies with number of sites placed.

Arestin® may be payable by pharmacy benefit plan of medical insurance.

REMOVABLE PROSTHETICS

IMMEDIATE DENTURE (D5131/5140)

Higher fee to cover “healing’ follow-up period.

Wait six months (after extraction[s]) for hard acrylic reline,

rebase, or new denture.


If followed by a completely new denture, ask for alternative

benefit of reline.

PARTIALS – FOUR TYPES

1. Resin Partial (D5211/D5212); Indefinite life

2. Cast Partial (D5213/D5214); Indefinite life

3. Flexible Partial (D5225/D5226); Indefinite life


4. Interim Partial (D5820/D5821); 1-12 month life, duration (waiting

on Perio, bridge, implant, etc.) not filed with insurance.

“FLIPPER PARTIAL”*

Can be either Resin Partial (D5211/D5212), Valplast Partial (D5225/D5226).

OR

Interim Partial (D5820/D5821) depending on use


Interim Partial (D5820/D5821), depending on use

*Proper code depends on “life” expectancy and use of partial.

RELINE OR REBASE?

A reline maintains original acrylic base and is re-surfacing.

A rebase strips acrylic back to the teeth and all new base acrylic is


A rebase strips acrylic back to the teeth and all new base acrylic is applied.


LAB/CHAIRSIDE RELINE

A chairside reline sets at chairside.*

A lab reline is processed in the office or by an outside lab.


*This is not tissue conditioning. Tissue conditioning is preliminary to a definitive impression for a prosthesis.

IMPLANTS

IMPLANT INSURANCE COVERAGE

Must have Implant rider for coverage of Implant procedures.

Generally only a Crown will be paid as an alternative benefit for the


Implant, Abutment, and Implant Crown with a conventional plan.

SURGICAL IMPLANT PLACEMENT(ENDOSTEAL IMPLANT)

D6010 Full Size Implant-$1,500 - $2,000


D6010 Mini Implant-one-half fee

RADIOGRAPH/SURGICAL IMPLANT INDEX, BY REPORT

D6190 Implant Index


D5982 Surgical Stent-Not an Implant Index-Error

D5988 Surgical Splint-Not an Implant Index-Error

COMMON GP CODING ERRORS

1. Get mixed up between Abutment-supported and Implant-supported


crown

2. Report an implant crown as a natural tooth crown


IMPLANT CHARGE OUT POSSIBILITIES

Hardware Placement

Prefabricated Abutment (6056)

Custom Abutment (6057)


FURNISH PREFABRICATED ABUTMENT TO GP*

D6199 unspecified implant by procedure, by report.

*Oral Surgeon cannot report a Prefabricated Abutment (D6056).


Implant-Type Crown Codes

1. Abutment-Supported Examples:D6058 Porcelain/CeramicD6059 PFM Hi-NobleD6062 Gold Hi-Noble


D6062 Gold Hi-Noble

2. Implant-Supported Examples:D6065 Porcelain/CeramicD6066 PFM (Any Metal)D6067 Gold (Any Metal)

IMPLANT BRIDGEWORK CODING MATCH

Match Pontic and retainer coding

Implant Pontic is the same as natural tooth Pontic


Match material type (ceramic, PFM, gold)

IMPLANT PROVISIONAL CROWN PLACEMENT

D6199 unspecified implant procedure, by report (place provisional crown on Abutment/Implant)


crown on Abutment/Implant).

DENTAL IMPLANT SUPPORTED CONNECTING BAR

D6055 Implant Connecting Bar


Typically a removable Implant Overdenture fits over the Bar.


OVERDENTURE-COMPLETE

D5860 Natural tooth Overdenture


D6053 Implant/Abutment supported Implant Overdenture

OVERDENTURE LOCATOR CODES

Mini-Implant OverdentureD5862 Mini-Implant Cap embedded in overdenture.

F ll Si e Implant O erdent re


Full-Size Implant Overdenture D6056 plus D5862 locator.

IMPLANT MAINTENANCE PROCEDURE

D6080 Implant Maintenance Procedures-including removal of Prosthesis, cleansing of Prosthesis and Abutments, and reinsertion of Prosthesis.


Includes Prophylaxis.

X-Ray films and Oral Evaluation (Exam) are reported separately.

With natural teeth, Prophylaxis D1110 could be reported separately .

IMPLANT-RELATED REPAIRS

D6090 Repair Implant Supported Prosthesis, by report (any part of Prosthesis).

D6095 Repair Implant Abutment, by report (any part of Prefabricated [D6056] or custom [D0657] Abutment).


D6091 Replacement of Semi-Precision or Precision Attachment (male or female component of Implant/Abutment supported Prosthesis, per attachment .

BRIDGEWORK

BRIDGEWORK CODING MATCH

Match pontic and crown retainer

Match material type


Pontic code is the same for a natural tooth and implant bridge.


MARYLAND BRIDGE

Metal Wings (D6545)

Ceramic Wings (D6548)


Plus Appropriate Pontic

Charge ½ to ¾ Crown Fee for each “Wing”

ORAL SURGERY

CORONAL REMNANT: DECIDUOUS TOOTH (D7111) PRICING

A remnant is the Crown (no root) of a primary tooth.

Routine Recall Visit - No Charge


Emergency Visit Basis - $65.00

(Consider as office visit fee for operatory setup, filing, insurance, etc.)

ERUPTED TOOTH EXTRACTION (D7140)

Erupted Tooth (D7140):

Single, multiple, permanent and primary teeth extraction

Er pted Root (D7140):


Erupted Root (D7140):

Code also applies to exposed roots (not requiring surgical access)

SURGICAL EXTRACTION (D7210)*

Requires removal of bone and/or section of tooth.

“Suture” does not count.

Pays about 60% - 90% more than (D7140) due to time and difficulty.


Document in clinical notes

* Effective 1/0/11, a flap is optional.

SURGICAL EXTRACTION OF RESIDUAL TOOTH ROOTS (D7250)

Cutting procedure to remove bone/residual roots.

“Residual” generally means roots left by someone else.


Use of this code may trigger denial of bridgework or implant coverage due to “missing tooth” clause.

Common code associated with denture fabrication (removing roots) or use by oral surgeon to remove roots left by previous dentist.


CORONECTOMY (D7251):INTENTIONAL PARTIAL TOOTH REMOVAL (1/1/11)

Intended partial removal

Impacted Tooth


Avoids complications of inferior Alveolar Nerve and Lingual Nerve

D7295: HARVEST OF BONE FOR USE IN AUTOGENOUSGRAFTING PROCEDURE (1/1/11)

Existing codes D7953 (Bone Socket Graft) and D7955 refer to

Autogenous Graft. D7955 specifically states that obtaining the


Autogenous Graft. D7955 specifically states that obtaining the

graft is not included.

GRAFTS FOR IMPLANTS

D7950 Graft of Edentulous Area of Mandible or Maxilla-Autogenous or Non-Autogenous, by report. (Includes obtaining Autograft and/or Allograft material. Membrane Extra.

D7951 Sinus Augmentation with Bone or Bone Substitutes.


D7951 Sinus Augmentation with Bone or Bone Substitutes. (Includes obtaining graft material but excludes membrane, if used).

D7953 Bone Replacement Graft for extraction or implant removal (01/01/11) site. Does not include membrane, if used. Does not include harvesting bone.

D7295 Harvest of Autogenous Bone may be used 01/01/11.

FRENUM EXCISION CODES

Frenulectomy (D7960)Release of bucal, labial, or lingual frenum “clip and snip”. Lower fee.

Frenuloplasty (D7963)


Frenuloplasty (D7963)Excision of frenum plus repositioning of Aberrant muscle and z-plasty or local flap closure.More complicated and a higher fee.

OTHER SURGERY CODES

Tooth stabilization after injury (D7270)

Soft-Tissue Biopsy* (D7286)

® *


OralCDx® Biopsy* (D7288)

Excision of Pericoronal Gingiva (D7971)

*For biopsy, wait on pathology report before filing a dental claim.

OCCLUSAL ORTHOTIC DEVICE (TMJ) - (D7880)

Patient exhibiting “signs and symptoms of TMJ.”

Treatment is splint, occlusal adjustment, multiple visits

Not bruxism which is an occlusal guard (D9940)


Generally not paid under dental insurance, except TMJ rider.

File medical for payment.*

*Infrequently there is medical reimbursement.


ORTHODONTICS

TYPICAL ORTHO CASE TYPES

Interceptive Case - Child

fixed, removable (D8060)

Limited Case - Adult


fixed, removable, Invisalign® (D8040)

Comprehensive Case - Adult

fixed, removable, Invisalign® (D8090)

NO DISTINCTION IN FIXED, REMOVABLE OR INVISALIGN® TREATMENT.

COMPREHENSIVE ORTHODONTIC CASE

NO DISTINCTION IN FIXED, REMOVABLE OR INVISALIGN TREATMENT.

HABIT APPLIANCE*

Removable Appliance Therapy (D8210)


Fixed Appliance Therapy (D8220)

* Harmful habits such as thumb-sucking and tongue thrusting.

ORTHODONTICS? YES NO

Extractions

Transseptal Fiberotomy


Frenectomy

Unerupted Tooth Exposure

Placement of Device (Button)

ANALGESIA

N2O: Not Payable (D9230)

Non-IV Sedation: Not Payable Generally (D9248)



SECTION BRIDGE (D9120)

Section bride and polish remaining retainer.

Charge extraction plus D9120.


OCCLUSAL GUARD (D9940)

Not TMJ (D7880) or Athletic Mouth Guard (D9941)

For Bruxism and Perio Stabilization Only

Three Types of Occlusal Guards:


1. D9940A – Soft (suck-down)

2. D9940B – Hard (lab fee - $100)

3. D9940C – NTI

Fee: $350 - $650 +Typically 2 or 3 Total Visits

OCCLUSAL GUARD (D9940) (CONTINUED)

Documentation: Always use a narrative.

Mention Bruxism/Clenching.

Mention patient has undergone periodontal therapy, if appropriate.


Six month rule-For Perio coverage, the Occlusal Guard maybe

required for delivery within six months of SRP or Osseous Surgery.

Note: D4341/D4342 or Osseous Surgery is required for Perio statement.

Report as Upper and Lower Arch Separately

TOOTH WHITENING (D9972)

Code Advisor

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The Insurance Solutions Newsletter is published bi‐monthly and over ten thousand dental practices rely on it to help them understand how to use current dental codes, develop effective narratives, monitor the industry’s migration towards risk‐based dental benefits, and understand carriers’ and providers’ rights and responsibilities regarding prompt payment and insurance refund requests. Subscribers receive free toll‐free telephone support for dental coding and basic medical billing in addition to access to the popular Insurancebilling in addition to access to the popular Insurance Solutions' Online Coding Forum.

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Documents

RESENTED BY CHARLES BLAIR D. S